Residents Report

Wednesday November 30, 2005

Jason Ryan, MD

Valve Projection Areas

Cardiac Auscultation
Murmurs
Systolic
Ejection Implies either obstruction or high output

Obstruction: AS, HOCM, rarely PS

High output: Anemia, Thyrotoxicosis, AR, ASD, VSD
Innocent murmur: Mid-systolic, best at LSB, non
radiating

Pansystolic Implies retrograde flow from high to

low pressure chamber
MR, TR, VSD

Cardiac Auscultation
Murmurs
Diastolic
Retrograde flow across incompetent valve
AR, PR

Diastolic filling
MS

The 6 Must Know Murmurs

1. Aortic Stenosis
2. HOCM
3. Mitral Regurgitation
4. Mitral Stenosis
5. Aortic Regurgitation
6. Tricuspid Regurgitation

Aortic Stenosis
Systolic ejection murmur that usually peaks in early systole
Location: Classically heard best in right 2nd interspace
As the degree of AS worsens, the murmur peaks closer to S2
(i.e. later).
In general, the later the peak and the louder the murmur, the
more severe the stenosis.
Often radiates to the carotids
Carotid upstrokes are delayed!

In reality, often loudest in a sash or shoulder harness area

from second right interspace to apex

HOCM
Caused by outflow tract obstruction
Location: 3rd or 4th left interspaces
Can sound just like AS unless you do
maneuvers!
Increasing size of LV makes murmur softer
Squatting (raises BP)

Decreasing size of LV makes murmur louder

Valsalva (intrathoracic pres VRLV)

Valsalva: HOCM gets louder, AS gets softer

Squatting: HOCM gets softer, AS gets louder

Mitral Regurgitation
Holosystolic murmur
Location: Heard best at the apex
Radiates to the axilla
Pearl: Presence of S3 suggest severe MR
Bonus trivia: What is the Gallavardin phemonena?

Mitral Stenosis
Causes either (or both) an opening snap or a
diastolic rumble.
Location: apex
More bonus (read: useless) trivia: What is the
Austin Flint murmur?

Aortic Regurgitation
Early diastolic murmur. Blowing.
Often associated with systolic ejection murmur from high
stroke volume
Location: Heard best at LSB in 3rd or 4th IC space
Wide pulse pressure

Tricuspid Regurgitation
Holosystolic murmur
Causes: RV failure and dilation,
Pulmonary hypertension of any cause
Location: Heard best at left lower sternal
borderer
Clues:
Intensity may increase with inspiration
Look for large v waves in neck veins

Pearls
PDA

Continuous, machine-like murmur

ASD

Fixed split S2

VSD

Usually a pansystolic murmur

AV Dissociation

Cannon AV waves, pounding in neck

MVP

Mid-systolic click
different from an opening snap which is diastolic

Pearls
Normal heart sounds:

S1

S2

S1

A2 P2

Inspiration causes physiologic splitting

Pearls
Normal heart sounds:

S1

S2

S1

A2 P2

A Right Bundle Branch Block delays P2 causing

a widely split S2 which is a persistent split that
widens with inspiration:

S1

A2 P2

S1

A2 P2

Pearls
Normal heart sounds:

S1

S2

S1

A2 P2

A Left Bundle Branch Block delays A2 causing

a paradoxically (or reversed) split S2 which is
a split that occurs with expiration and disappears
with inspiration:

S1

P2 A2

S1

S2

Question 1
1. A 60-year old man has a 2-month history of
progressive dyspnea and chest pain. Cardiac
auscultation reveals a grade 3 systolic ejection
murmur that is heard best at the second right
interspace. The murmur radiates into the carotid
arteries. What is the most likely underlying valvular
abnormality?
1. Aortic regurgitation
2. Aortic stenosis
3. Mitral regurgitation
4. Mitral stenosis

Answer 1
Aortic stenosis. Systolic ejection murmurs
are caused by outflow obstruction. Their
intensity peaks in midsystole and is
described as a crescendo-decrescendo or
diamond-shaped murmur. The murmur of
aortic stenosis is an example of a systolic
ejection murmur. The murmur radiates
along the outflow track (ie, into the carotid
arteries).

Question 2
A 50-year-old woman has a 3-month history of
progressive dyspnea. Cardiac auscultation
reveals a grade 3 pansystolic murmur heard
best at the apex. The murmur is medium-pitched
and radiates to the axilla. What is the most likely
underlying valvular abnormality?
1. Aortic regurgitation
2. Aortic stenosis
3. Mitral regurgitation
4. Mitral stenosis

Answer 2
Mitral regurgitation. Pansystolic murmurs
are almost always caused by reverse flow
across a valve. The single exception
occurs in cases of a ventricular septal
defect, in which blood flows across an
orifice in the septum. The murmur of mitral
regurgitation radiates into the axilla in the
direction of the flow.

Question 3
A 40-year-old woman has a 3-month history of
progressive dyspnea. Cardiac auscultation reveals a
grade 3 diastolic murmur heard best at the apex. The
murmur is low-pitched and has a rumbling quality.
There is a snapping sound that immediately
precedes the murmur. What is the most likely
underlying valvular abnormality?
1. Aortic regurgitation
2. Aortic stenosis
3. Mitral regurgitation
4. Mitral stenosis

Answer 3
Mitral stenosis. The murmur of mitral
stenosis is generated during left atrial
contraction as blood is being forced
through the narrowed mitral valve. There
is usually an opening snap just before the
diastolic rumble begins.

Question 4
During a routine physical examination of a 30-year-old
man, cardiac auscultation reveals a grade 3 systolic
ejection murmur heard best at the left lower sternal
border. The murmur does not radiate into the carotid
arteries and becomes louder when the patient is asked
to perform the Valsalva maneuver. What is the most
likely underlying cardiac abnormality?
1. Aortic stenosis
2. Dilated cardiomyopathy
3. Hypertrophic cardiomyopathy
4. Mitral regurgitation

Answer 4
Hypertrophic cardiomyopathy. Systolic
ejection murmurs are caused by outflow
obstruction. In this case, the obstruction of
the outflow tract results from asymmetrical
hypertrophy of the ventricular septum. The
murmur is worsened with performance of
the Valsalva maneuver, because the
outflow obstruction is increased.

Question 5
During a routine physical examination of a 15year-old boy, cardiac auscultation reveals a grade
3 systolic ejection murmur heard best at the left
second interspace. S2 is widely split and fixed (ie,
does not vary with respirations). What is the most
likely underlying cardiac abnormality?
Atrial septal defect
Ventricular septal defect
Aortic stenosis
Pulmonic stenosis

Answer 5
Atrial septal defect. The systolic ejection
murmur produced by an atrial septal
defect results from increased flow across
the pulmonic valve. The right ventricle has
increased filling as blood is shunted from
the left atrium to the right atrium and finally
into the right ventricle. There is fixed
splitting of S2 because of continued delay
in the closure of the pulmonic valve.

Question 6
A 20-year-old female is evaluated for palpitations. She has noticed
rapid pounding in her chest on several occasions. She is most
aware of pounding in her neck. Most episodes last less than 1
minute, but a few have lasted one half hour. During an episode she
is lightheaded, but does not have syncope, chest pain, or shortness
of breath. Symptoms usually occur without warning at rest. If she
breathes slowly and deeply, the episodes usually stop on their own.
Recently, the episodes have been more frequent. Her EKG and
physical exam are normal.
Which is the most likely diagnosis?

1. Benign premature atrial contactions

2. Palpitations related to MVP
3. Paroxysmal SVT
4. Ventricular Tachycardia
5. Paroxysmal atrial flutter

Answer 6
Paroxysmal SVT. Aburpt onset and
regularity of patients symptoms suggest
SVT. The pounding in the neck is related
to cannon A waves, caused by atrial
contraction against a closed valve. PSVT
in young women is usually AVNRT and is
much more common than than VT or
Aflutter.

Question 7
A 25-year-old pregnant woman is referred to you because of a heart
murmur noted during the second trimester of pregnancy (her first
pregnancy). The patient has no history of cardiac disease and the
murmur was not noted during previous exams. She is
asymptomatic. Exam shows a mildly displaced apical impulse and
lower extremity edema. S1 and S2 are normal and an S3 is noted at
the apex. A grade 2/6 early to mid-peaking systolic murmur is
audible at the left sternal border.
Which of the following is most likely?

1. Bicuspid aortic valve with mild to moderate stenosis

2. Congenitally abnormal pulmonary valve with moderate stenosis
3. Physiologic murmur related to pregnancy
4. Mitral valve regurgitation related to MVP
5. Bicuspid aortic valve with moderate regurgitation

Answer 7
Physiologic murmur related to pregnancy.
S3 is audible in 80% of pregnant women.
An early peaking ejection systolic murmur
(flow murmur) is audible in 90% of
pregnant women. Apical displacement is
common because of the increase in blood
volume the occurs in later pregnancy.

Question 8
A 26-year-ol man seeks your advice because he was
diagnosed as having a heart murmur as a baby. At that
time, his parents were told he would outgrow the
murmur. The patient participates actively in sports
without any cardiac symptoms. On physical exam, S1 is
normal, S2 is physiologically split. A thrill is noted in the
third left intercostal space and a 4/6 holosytolic murmur
is noted along the left sternal border radiating to the
right. No S3 or S4 are heard.
Which of the following is most likely?

1. Aortic stenosis
2. Mitral regurgitation related to MVP
3. VSD
4. Cardiomyopathy

Answer 8
VSD. VSDs create very loud heart
murmurs that are holosystolic (often they
also cause a thrill). None of the other
answers fit with the exam.

Question 9
A 42-year-old woman comes to your office for evaluation
of angina and dyspnea on exertion for 6 months. She
has no cardiac history other than a long standing
murmur. On physical exam, she has a normal S1 and
S2. An S4 is noted. She has a grade 2/6 late-peaking
systolic ejection murmur that increases with valsalva as
well as when she rises from squatting to standing.
Which of the following is most likely?

1. Aortic Stenosis
2. HOCM
3. Mitral Regurgitation
4. VSD

Answer 9
HOCM. Angina and dyspnea are
symptoms of progressive obstruction.
While this can also be cause by AS, a
murmur that increases with valsalva (i.e.
deceased preloaddecreased LV size) is
consistent with HOCM.

Welcome to the Applicants!

The End.